Another Attempt to Make Psychiatric Diagnosis Meaningful

Psychiatrists are about to come up with the fifth iteration of the Diagnostic and Statistical Manual of Mental Disorders, 18 years after DSM 4. This important book is a compilation of various psychiatric disorders. It is important because it used to determine whether or not treatment will be reimbursed by insurance companies. There is hope, also, that rigorous diagnosis will make it possible to study these disorders more effectively. The conditions described therein are for the most part familiar to psychiatrists and patients, although, unfortunately, the way they are described has changed over time and from place to place. Sometimes their names have changed. What was known in the past as manic-depressive illness, for example, is currently called bipolar disorder. Other conditions, such as homosexuality have been dropped altogether. At one time homosexuality was considered an illness; and then, sometime later, it was no longer an illness, according to a majority vote of clinicians. Such is the nature of psychiatric nomenclature.

Contrast that with diagnosis in the rest of medicine. Most medical illnesses are not voted in or out, depending on the whim of professionals in the field. Tuberculosis has been tuberculosis ever since the bacterium that causes the disease has been discovered. Whether it is in the bones or the lungs, whether it is severe or mild, it is still called tuberculosis. Psychiatric disorders do not have this character.

Much of psychiatric terminology is descriptive only. Most of these conditions are not determined by any objective evidence for disease, in the ordinary sense of the word objective. Certain signs and symptoms seem to group together. They are, insofar as they are anything, a constellation of symptoms—a syndrome . They are defined as illnesses because they cause distress to the individual who complains of these symptoms—or, possibly, because they cause distress to other people. In that sense, they are pathological and worthy of treatment. But are they real?

Validity: The validity of a diagnosis addresses the question of whether or not the particular disorder described is real. Is there such a thing as a Major Depression, or a Schizophrenia, or a Borderline? Or are these just terms invented by someone to describe what strikes that person as a commonality between different patients? Take the diagnosis of Borderline. (I have heard clinicians speak seriously of a Borderline Borderline.)

There was a time some years ago, when some psychiatrists noticed that there were patients who demonstrated certain elements of psychosis, but presented mostly with symptoms associated with neurosis, a less serious category of mental illness. These doctors took the opportunity to invent a new kind of illness: the pseudo-neurotic schizophrenic, or, in the usage of others, the borderline. This is an example of trying to convince oneself that we know something about a condition if we give it a name. Initially, the term Borderline was used differently by different psychiatrists; but then a consensus formed. This is a summary of the way Borderline is described in the DSM-4:

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts as indicated by five (or more) of the following: (There is not space here to describe all nine of the behaviors singled out for inclusion) but they involve: 1. Efforts to avoid abandonment 2. Unstable and intense relationships. 3.Unstable self-image 4. Impulsivity that is likely to be self-destructive 5. Recurrent suicidal or self-destructive behaviors. 6. Instability and reactivity of mood. 7, Feelings of emptiness. 8. Inappropriate anger 9. Transient paranoid ideation.

Can the diagnosis be made with only four of these behaviors? Would that be the Borderline Borderline alluded to above? Are some of these behaviors present, at least transiently, in most people? I think so.

Speaking of behaviors or feelings or other qualities of mind as if they constitute a thing is called reification. A common example is Freud’s description of the unconscious. The unconscious is not just an inclination to remember, or not remember, or behave in a certain way, it is treated as an object, something that has an existence with all the features of an object—a place, a shape, a kind of weightiness. This sort of logical error can lead people to misunderstanding. Has this happened with the diagnosis of Borderline? I think so. Before someone invented this term, A Borderline patient might have been described simply as depressed, or impulsive, or, even, immature. Do some of these symptoms appear together? Yes. But they may be a developmental stage in some people rather than a mental condition in its own right. What is also true is that some Borderlines no longer exhibit these behaviors after a time, whether or not they have been in treatment. Is it reasonable to describe it as a particular condition, like schizophrenia is a condition? I don’t think so. Yet, this diagnosis has become popular.

One would think that the diagnosis of an illness would not become popular or unpopular, in the same way a particular author or a band might become popular or unpopular, simply because of the tastes of other people all changing at the same time, but in the matter of psychiatric diagnoses, that is the case.

There was a time when the diagnosis of manic-depressive illness vs. schizophrenia was different in England and in America. The British were more likely to call a patient described in a particular way as a manic-depressive. The same description presented to American psychiatrists led to a diagnosis of schizophrenia. When lithium was discovered to be an effective treatment for manic-depressive illness, that condition was diagnosed more readily by everyone. If one did not know about the use of lithium, it would have seemed that the condition had suddenly become rampant.

Currently, popular diagnoses include attention deficit disorder and bipolar disorder. This is likely to represent a fashion in diagnosis rather than an increased incidence of those conditions. The reason why it is possible to decide arbitrarily that a condition is present or not is the fact that there are no objective tests for these conditions. The psychological tests for ADD are not reliable, or valid; and there is no objective test for bipolar disease at all. In fact, the reason why there is a new Diagnostic and Statistical Manual, and there have been four previous attempts to write such a manual, is that most of the disorders described in these compilations are descriptive only. Nevertheless, some psychiatrists are inclined to take the matter of diagnosis quite seriously

I saw a patient recently who had been treated successfully for a paranoid schizophrenia for many years with a relatively high dose of a neuroleptic. His first psychiatrist died, and he went to another who decided the patient was really bipolar. Because the first line drugs for bipolar disease are somewhat different than those prescribed for schizophrenia, he switched the patient to a different drug. The patient began to hallucinate and talk to himself. Shortly thereafter, he came to me; and I put him back on the first drug, after which he did okay. As it happened, it seemed to me clear enough that he was really a paranoid schizophrenic. But, suppose he was not. Why would someone stop a drug that was working simply because he thought the diagnosis was wrong?

The fact is, I think psychiatrists are usually in the position of treating symptoms—agitation, depression, dementia, etc.—rather than the underlying diseases that cause them. It is the symptoms that cause distress; and many of the same symptoms are present in different conditions.

Making meaningful diagnoses requires a true understanding of the illness. There was even a time when tuberculosis, when it presented primarily as a gastrointestinal disease (from unpasteurized milk,) could be confused with other intestinal diseases. It was only when the bacterial cause was discovered that that condition could be delineated accurately.

Similarly, I think psychiatry has simply not advanced far enough to distinguish sensibly one condition from another. We now have psychological syndromes that are called disorders. Many of the psychological symptoms referred to in these conditions are present in varying degrees in normal people. I think that when the biological causes –of the psychoses, at least—are delineated successfully, there will turn out to be different kinds of schizophrenia, for example, and depression. The patterns of thought, feeling and behavior that are now thought to be defining characteristics of these disorders will turn out to be a final, common pathway of different disorders.

For example, I have seen schizophrenic patients who did very well. Some have had one psychotic episode that left no sequelae and were not followed by further attacks. On the other hand, I have seen schizophrenic patients who deteriorated steadily despite good treatment into a chronic, disabled state which required permanent hospitalization. My hunch is that these extremes will be discovered to be caused by different biological defects—and will, therefore, appear someday in DSM 28 under different names.

Reliability: A diagnosis should call to mind the same clinical picture whoever uses that term. If one psychiatrist calls a patient a Borderline, other psychiatrists should be able to understand what he means. For this purpose, at least, the DSMs serve a useful purpose. But I think, by that standard, these extremely carefully written catalogues fail. Look at the definition of Borderline written above. What one clinician calls a Borderline is likely to differ considerably from the picture of a Borderline that the other clinician imagines.

In an attempt to make these diagnoses seem more specific than they really are, they are given identifying numbers. For instance, 315.31 signifies Expressive Language Disorder (whatever that is.) 300.21 stands for Panic Disorder with Agoraphobia. These numbers are used on insurance forms. If the diagnoses were reliable, at least we could make some inferences about the prevalence of a particular condition, and so on. But, judging from my experience, such an attempt would be futile.

I was treating a patient for Obsessive-Compulsive Disorder. I put the code 300.30 for that condition on the form required by Medicare. They returned it to me saying this code, which I had been using for years, was superseded by a new code. They explained this to me over the phone.

“All right,” I said, “what is the new code?”

“We can’t tell you?” a woman’s voice said.

“Why not?”

“That’s our policy.”

“How can that be?”

Silence.

“Well, how do I find out the right code?”

“I don’t know.”

I spent the next few days trying to locate a more recent copy of the international psychiatric code book, which is what I presumed had superseded DSM 4. Finally, although I did not feel sure, I filled out the form with 300.3. The form was returned to me about two weeks later. I called again to find out why.

“The code has to have five numerals,” a different lady informed me.

I yelled something or other; but this woman too refused to tell me the proper code.

Once again, I tried 300.30. It was returned again. Whereupon I did the sensible thing: I wrote in the code for a different disorder; and that was accepted. If a team of statisticians are going to try to glean some information from these forms about the incidence or prevalence of OCD, they are going to be misled.

For those of you who are keeping track: It seems that DSM 5 will eliminate the diagnosis of Asperger’s syndrome. Those who are currently thought to suffer from this condition will be subsumed under the diagnosis of autism. Frequent temper tantrums, which had not come to official notice up to now, are diagnosable as Disruptive Mood Dysregulation Disorder. People who find themselves somehow in the body of the wrong sex are now described as having gender dysphoria.

Please keep in mind that a great many very smart people have been laboring over the DSM 5 for many years.(c) Fredric Neuman Follow Dr. Neuman's blog at fredricneumanmd.com/blog

Good post, and a thoughtful critique. I think it is very clear that there are significant problems with psychiatry and psychology, in terms of the validity and reliability of diagnoses advanced in dsm. One fundamental "truth", i believe, is that many get into these fields out of a genuine desire to help others, but are soon confronted with the stark realities- not of the work- but of the business of mental heallth care. To be sure, psychiatry and psychology have strived to be legitimate fields, based in science, in order to provide effective care. Accordingly, insurance companies will only pay for care based on the developed codes, which you clearly point out. This not only leads to misdiagnosis, but overdiagnosis. Consider that no "good" clinician will do a full initial evaluation and not find one of the over 400 conditions in dsm, simply because he or she will not get paid if there arent 5 digits attached to it. Those good people wanting to really help others, yet burdened by debt from years of specialized training, are then drawn into ethical conflicts regarding diagnosis and disbursement. Do we notice that the most recent outspoken critics in these fields - psychiatry and psychology- have been those who have already completed their careers in the field...allen frances now, and loren mosher in 1998. Only szasz had the gumption not to buy in from the gate...The vast majority just want to pay down debt while retaining the social perks of doctoring. "Patients" grease this machine.

People can be helped without the fuzzy logic and stigmatizing labels attached to dsm. Given the "chinese menu" approach to diagnosis, i have always disagreed that dsm facilitates communications between providers. If anything, it is reductive and we end up talking about the "borderline" or the "depressive"...caricature instead of person. If they communicate anything, it is the relative ease with which a person can be "managed," not heard.